Archive for July 2011

We Americans can learn a great deal from our friends in the United Kingdom if we simply take the time to pay attention. For today’s lesson, we’re most grateful to Dr. Stephanie Dancer, Consultant Microbiologist at the NHS Lanarkshire, and fellow blogger The Ferret Fancier; the former for her work and permission to republish her presentation here, and the latter for bringing this whole thing to our attention. While the topic at hand is most directly about infection control and the best way to defend against the spread of methicillin-resistant Staphylococcus aureus (MRSA), the lessons and implications go well beyond infectious disease and take us on a short trip down the Road to Hellth.

For those of you who may not be in tune with such things, MRSA is a potentially harmful strain of bacteria that often infects wounds or breaks in the skin. It is highly resistant to treatment by conventional antibiotic therapy. MRSA bacteria are responsible for a substantial percentage of hospital-acquired skin infections, and such infections can be extremely expensive and difficult to treat. The bacteria can also be encountered among relatively healthy people in the larger non-hospital community – and is often spread as a result of sharing razors, sports equipment and other items that come in contact with the skin. As is the case with many health problems, this is one that we’ve largely created for ourselves through the ubiquitous and often indiscriminate use of antibiotics for everything from scratches to animal feed. Nevertheless it’s important to try to limit its spread because our treatment options for MRSA-related illness are rapidly disappearing.

We strongly encourage all of our readers to go through Dr. Dancer’s excellent slide show on the topic of MRSA embedded above. But for the benefit of any of our readers who may be time-constrained and/or impatient we’ll provide a short synopsis and make a couple of observations.

Soon after it became apparent the MRSA was a problem that would not go away, medical researchers began to think about how it might be possible to limit the spread of this organism in the hospital. One strategy that was formally investigated in the late 1990s was the enhanced use of hand washing among healthcare personnel. In 2000, Dr. Didier Pittet and his colleagues in Geneva Switzerland launched a study in which they carefully observed the hand washing practices of in-hospital providers and actively promoted hand hygiene, especially with the use of bedside alcohol-based gels, and tracked the impact on MRSA infections over time. One result was that while the hand cleaning rates among nursing and support personnel improved significantly over the three year study period, hand cleaning among doctors did not. A second result was that both hospital-acquired infections and the MRSA transmission rate fell substantially. The impact of this study was immediately felt around the world, as hospitals everywhere proceeded to launch intensive hand-cleaning programs of their own.

As people are wont to do in such cases, healthcare and political leaders everywhere began to look for ways to improve upon the hand washing crusade. “After all”, they reasoned, “if a little hand washing is good, more is better, right?” Administrators in the United Kingdom took the leadership bit between their teeth and began to run hard and fast.

As illustrated by Dr. Dancer, they launched into a fairly astonishing variety of interventions including the production of posters, life-size cardboard cutouts of admonishing nurses, audits, conferences, flyers, “hand-hygiene coordinators”, badgers badges, UV detectors, TV monitors, additional sinks, disinfectant dispensers, warning letters, flashing signs, committees, sniffer dogs, more audits, and lots of additional managers and administers to name just a few. In 2007 and 2008 three separate government departments came out with MRSA-related guidelines dictating that healthcare providers had to eliminate their personal use of wristwatches, jewelry, neck ties, white coats and pens or pencils in outside pockets. They were further instructed to go “bare below the elbow, and forbidden to leave work in their uniforms. Finally, on January 29, 2009 the government in Scotland really took the gloves off. It established a “zero tolerance policy” for providers who failed to wash their hands, complete with the threat of firing.

“A ‘zero tolerance policy’ for NHS staff who fail to wash their hands was today declared by the Scottish Government.

And the public will be able to check superbug infection rates and levels of hand cleanliness for each hospital under the new measures.

The latest moves in the battle against hospital infection were announced today by health secretary Nicola Sturgeon.

A ‘one-stop shop’ is to be set up to give public access to all published information on hospital infection rates and hand hygiene compliance.

This will be available on a website which will be established by the end of the month.

The ‘zero tolerance’ approach has been set out by the Scottish Government’s chief nursing officer, Paul Martin, in a letter to all health board chief executives.

The target level for compliance in Scotland is at least 90%. Overall, this target is being exceeded, at 93%.

But within this total, compliance levels vary from 95% for nurses to 84% for medical staff.

Ms Sturgeon said: ‘Hand hygiene is a simple, but essential, part of our drive to tackle infections in hospitals, for everyone from consultants to clerical staff.

‘That’s why we are now adopting a zero tolerance approach to non-compliance by NHS staff to ensure we build on the great progress that has already been made.’

The new drive includes an eight-week advertising campaign.”

Not to be left out, politicians “across the pond” in the U.S. have taken up the cause. In April of 2011, Sen. Jeffrey D. Klein and Democratic colleagues in the New York state legislature sponsored S4909, which mandates a “Health Care Practitioner Hygienic Dress Code” that is similar to the rules imposed in the U.K. At the time of this writing Senator Klein’s bill is still in committee, but infectious disease specialists have questioned its clinical value:

“The New York legislation “sort of verges on hysteria,” said James L. Cook, MD, chief of the Section of Infectious Diseases, Immunology and International Medicine at the University of Illinois College of Medicine in Chicago. “You’ve got to decide. Do you want to use the evidence? … There is nothing to suggest that anything you find on someone’s article of clothing is likely to be transmitted to a patient.”

Apparently undeterred by any potential criticism, however, the bill’s sponsors are continuing to forge ahead. Indeed, when asked to comment, Senator Klein even took an approach ironically reminiscent of Star Trek’s “Dr. Leonard McCoy:

“’I’m an attorney, I’m not an MD,’ said Klein, a Democrat who represents the Bronx. ‘This is a simple and noninvasive approach to alleviating the infections that are taking place in hospitals and which are a serious problem — not only in New York, but across the country.’”

This really brings us back to Dr. Dancer’s presentation. What does the medical evidence say about the top-down measures being imposed – as they invariably are – by the vast government bureaucracies governing healthcare these days? In a nutshell, it amounts to this:

Bare below the elbow? “Bare below the elbow improves wrist washing.” Unfortunately, there is no evidence that this provides any medical benefit.

Using alcohol gel? “No effect on MRSA.” It also does not appear to have any impact on the control of C. difficile infections or transmission of pathogens in the ICU.

Rabid hand cleaning vigilance? MRSA infection rates in hospitals have declined over the same period of time that these programs have been placed into effect, but so have efforts to enhance screening for MRSA, reduce infections caused by IV lines, and improve topical care. No one has yet sorted out how the benefits of hand cleaning compare with the impact of all these other interventions. Interestingly enough, despite all of these measures, infection rates of methicillin-susceptible Staphylococcus aureus have not changed at all. This suggests that the progress we’re making with respect to reducing MRSA-related infections mat well have nothing whatsoever to do with hygiene, but everything to do with more judicious use of antibiotics in the hospital.

Dr. Dancer then goes on to make a very good case that hospital overcrowding and a heavy load of bacterial contamination on the surfaces of everything one touches in NHS hospitals probably more than make up for any benefits garnered from all of this “zero tolerance” nonsense. After all, what good does it do to clean your hands in the very next thing you touch is already contaminated? In one study 5% of the fingertips of healthcare workers were contaminated with MRSA: 6% after clinical contact, 7% after environmental contact, and 4% after no specific contact. In fact, preliminary data shows that simply hiring additional cleaners can reduce the bacterial load in rooms by 33% and cut the rate of MRSA infections in half. Why haven’t the politicians and bureaucrats mandated that this be done routinely in NHS hospitals? Because it’s expensive relative to simply ordering doctors and nurses to do things that are highly visible, but have little or no real impact on infection rates.

Politics, anyone?

Let’s not kid ourselves. There’s still an enormous amount that we still don’t know about the best way to do many things in healthcare. Any physician who’s been in practice more than ten years can point to a host of “facts” (s)he learned about the cause and treatment of illness that are now known to be completely wrong. And when it comes to making improvements, the obvious is often faulty. It was “obvious” that electronic medical records would save the healthcare system billions each year in time and money; our experience thus far has been disappointing to say the least, (with the NHS again leading the way). It was “obvious” that having the government fix the price of healthcare goods and services for the past 40 years would lead to healthcare cost containment. We all know how that turned out. And now it’s “obvious” that an unaccountable board of unelected “experts” like ObamaCare’s Independent Payment Advisory Board can magically control the cost of Medicare without reducing benefits, quality or access to care.

So let’s learn one thing from our British cousins, shall we? When it comes to a clearly medical problem such as infection control, the best thing our political and bureaucratic leaders can possibly do is politely ask the medical community to: (1) seriously research the problem; and (2) implement medically valid solutions based upon their findings. Don’t pass laws. Don’t generate regulations. Don’t specify behavior or procedures. Just ask the medical community to do the best it can. Then go right back to placing your own economic, ethical and political house in order.

If the AMA really did have the best interests of physicians in mind and wanted to do something good for patients and physicians, they’d forget about theirlousy advertising campaigns and commission a whole line of books just like the newest literary work from the folks over at the Shrink Rap blog, Dinah, ClinkShrink and Roy. Every specialty could use one. More on that in a bit.

For those of you who may not follow their blog regularly or may not have noticed it in the “Clinical Care” section of Healthcare Roundup, Shrink-Rap-the-blog is hosted by three enterprising psychiatrists from Maryland, whose real names are Drs. Dinah Miller, Annette Hanson and Steven Daviss. The members of this trio happen to practice in very different clinical environments: Dinah is a general adult outpatient psychiatrist, Annette works in prison as a forensic psychiatrist, and Steve works in a general hospital setting. Together with their guest bloggers they regularly produce an entertaining blog (and separate My Three Shrinkspodcast) “by psychiatrists for psychiatrists”.

In Shrink-Rap-the-book, they’ve taken on an entirely different task – that of explaining the basic art, science and economics of psychiatry to those of us who aren’t psychiatrists. Why? Who knows? Maybe it’s a piece of self-prescribed psychotherapy. But the result is superb on many levels.

Shrink Rap the book tries to several things simultaneously. As a guide for patients and their families it takes the reader through a number of prototypical (but imaginary) cases in which patients have common mental illnesses. These include depression, bipolar disease, anxiety disorders, addictions, schizophrenia, antisocial personality disorder and others. The authors use these cases as an opportunity to teach patients and families about the process of psychiatric evaluation and diagnosis, as well as specific therapies such as medications, psychotherapy and electroconvulsive therapy (ECT). The result is a surprisingly readable lesson on what to expect from the psychiatric process.

But rather than just stopping there, the trio also does something that is a great service to all clinicians: they also write about the economic, administrative, legal and political environment under which physicians and patients must operate when dealing with these conditions. The addition of this information is a great gift because frankly it’s impossible for anyone to truly understand what’s happening (and why), without it. Doctors and patients can’t necessarily do things just because they make sense medically and/or socially; there are many other factors at work. It’s absolutely critical to the future of medicine that patients and their families understand this.

For clinicians, medical students, residents and those simply interested in this field of medicine, the book offers another perspective entirely. Each of the authors provides a description of what clinical practice is like in his or her respective environment: outpatient clinical practice, hospital-based psychiatry or corrections. This brought back memories of my own days as a fourth year medical student rotating between the clinic, the hospital (including the locked wards in the public hospital in St. Louis), and the emergency room. It would have been great to have been better prepared for the experience with a book of this kind.

Finally, there is Shrink Rap, the book, as a piece of literature. There’s good news on this front as well. All three authors are fine writers and succeed in keeping the story flowing. In fact, based on what it appears the authors were trying to achieve, it’s hard to come up with a single useful criticism.

Getting back to the point I made earlier in this review, there is no question in my mind that Shrink Rap represents the type of communication and education that the medical community needs to be doing in order to redefine the profession in the minds of patients, families and the general public. Physicians have allowed others to define them, especially their motives and the extent of their power, for far too long. Under this scenario, doctors are selfish luddites; deliberately holding the healthcare system hostage with their resistance to “progress” in the form of electronic medical records, their reluctance to willingly participate in counterproductive insurance plans such as Medicare and Medicaid, and use of expensive medications rather than spending time with patients. The reality is, of course, quite different. Clinicians live in a world forced on them by the government and insurers. It’s a world that often makes it impossible to provide good, economical care. As a result politicians and other special economic interests have a great deal to gain by portraying clinicians as greedy, omnipotent villains. It makes it easier to shift the blame for rising costs, poorer service and piles of paperwork from the administrators onto the folks in the trenches. Removing clinicians from the moral high ground is a crucial step in the process.

Books like Shrink Rap present a problem for politicians and bureaucrats in that they present the promise and limitations of modern American medicine to the public in a direct, honest and understandable way. The only thing worse for the folks behind schemes like the mandatory deployment of complex, expensive electronic records and largely useless “quality” programs would be to see dozens of similar books hit the shelves and television airways – each focusing on a different medical specialty. The public should have a general understanding of important illnesses as well as the relative roles of patients, clinicians, and the economic, medical and political environments in treating them. It would make the discussion of healthcare reform a great deal more meaningful. This edition of Shrink Rap is an excellent beginning.

The bottom line: if you or anyone you know has any interest in the world of psychiatry, do them a favor and have them “Shrink Rapped”. It’s a very worthwhile read.

This is our third and last post examining the question of whether it’s possible to mitigate the actual harm that government control of healthcare is likely to entail. In our first post on the topic, we established that government is perfectly capable of botching up just about anything. In the second post we looked at the rapidly expanding role of unfettered government bureaucracy, as well as some very convincing arguments that it now constitutes an entire independent fourth branch of government unto itself. What we’ll explore in this post is whether it’s possible to limit the damage that is frequently done by Congress itself.

Legislators are the elected representatives of the people. One problem with that is that they’re frequently not experts at anything other than how to get elected. This has serious implications for Congressional control of any industry, but especially a diverse, highly complex and scientifically based industry like healthcare. First, it means that legislators must generally rely on others to influence (or even make) their decisions. These “other parties” typically include staffers, lobbyists, spouses and special interest groups – hardly a guarantee of sound and carefully considered policy. Second, it increases the likelihood that legislators try to address symptoms rather than actual problems themselves. We saw this in a myriad of ways with the Accountable Care Act (the “ACA, or “ObamaCare”). Just one circular example:

Symptom: People don’t have access to healthcare services.

Solution: Give them Medicaid, even though fewer and fewer doctors can afford to take it.

Symptom: Doctors can’t afford to see Medicaid patients.

Solution: Raise payments to providers for two years as more people are added to the Medicaid rolls, then lower them back to previous levels.

Symptom: We can’t afford Medicaid.

Solution: Cut payments to providers still further.

Anyone can see that all of this reacting has accomplished exactly nothing except to generate a lot of additional expense and dashed expectations. There is little or no understanding that healthcare is an ecosystem. You can’t just tweak it here or there and expect there not to be adverse and undesirable consequences.

As nearly as we can tell, there are three possible solutions to the dilemma of unsophisticated legislators: (1) elections that yield better candidates, (2) education and (3) the scientific method.

We’re going to rule out the idea of routinely electing people who have a great deal of intelligence, knowledge, skill and expertise right away. This is, after all, still planet Earth and we’re talking about the election behavior of homo sapiens. So we might as well take it as a given that the quality of our elected officials is not about to improve anytime soon. That leaves education and the scientific method as the only tools available.

Educating our elected representatives to a level that’s high enough to allow them to make good decisions about healthcare is certainly a challenge. Legislators are routinely asked to weigh in on topics ranging from whether bombing Libya constitutes “hostilities” to whether chickens ought to be raised in cages. It’s obviously unrealistic to expect them to learn a substantial amount about all of these topics; thus the division of research sessions called “hearings” among hundreds of different committees and sub-committees. Committee members are supposed to become experts on the topics they cover and then recommend bills to their legislative colleagues. They may or may not succeed in this regard, but even this doesn’t solve the basic problem of topical ignorance – the vast majority of representatives will ultimately be called upon to vote about things they know little or nothing about.* This renders the debates that take place on the floors of the House and Senate as the last possible opportunities to educate our representatives before the vote. But this simply raises another problem.

Question: who are the people speaking in these debates?

Answer: the representatives themselves, most of whom know little or nothing about the issue under consideration and whose arguments need not contain any factual information.

In practical terms it’s not much different from asking a class of fourth graders learn history, math and science by all sharing what they know or may have heard on television or around the dinner table.

As it happens, one potentially useful way to deal with this problem would be to take a lesson from God, (well, from the Vatican, anyway), in the form of a “devil’s advocate”. What’s a devil’s advocate? We don’t often quote Wikipedia, but this post seems to be pretty accurate:

“During the canonization process of the Roman Catholic Church, the Promoter of the Faith (Latin: promotor fidei), popularly known as the Devil’s advocate (Latin: advocatus diaboli), was a canon lawyer appointed by Church authorities to argue against the canonization of the candidate. It was their job to take a skeptical view of the candidate’s character, to look for holes in the evidence, to argue that any miracles attributed to the candidate were fraudulent, etc. The Devil’s advocate opposed God’s advocate (Latin: advocatus Dei; also known as the Promoter of the Cause), whose task is to make the argument in favor of canonization. This task is now performed by the Promoter of Justice (promotor iustitiae), who is in charge of examining how accurate is the inquiry on the saintliness of the candidate.

The office was established in 1587 during the reign of Pope Sixtus V and abolished by Pope John Paul II in 1983. This reform changed the canonization process considerably, helping John Paul II to usher in an unprecedented number of elevations: nearly 500 individuals were canonized and over 1,300 were beatified during his tenure as Pope as compared to only 98 canonizations by all his 20th-century predecessors, which has led many to question the validity of the process and whether all of those canonized today are deserving of the recognition. Such a dramatic increase suggests that the office of the Devil’s Advocate had served to reduce the number of canonizations. It is argued that it served a useful role in ensuring that canonizations did not proceed without due care and hence the status of sainthood was not easily achieved. In cases of controversy the Vatican may still seek to informally solicit the testimony of critics of a candidate for canonization. The British-American columnist Christopher Hitchens was famously asked to testify against the beatification of Mother Teresa in 2002, a role he would later describe as being akin to ‘representing the Evil One, as it were, pro bono’.”

One can see this immediate appeal of this approach as applied to legislation and the education of our legislators. Two independent and unbiased (in that they have no vested interest one way or another) experts would be appointed to carefully review each piece of legislation on their given topic. One would act as an advocate, while the other would act as a devil’s advocate. Each would speak in factual terms for a given period of time that would be proportionate to the relative importance and size of the legislation. A legitimate explanation of legislation as massive as the ACA might take weeks or months, enough time to perhaps prevent its passage on the basis of sheer size and complexity alone. The explanations and arguments posed by both advocates can and should be widely televised. You can readily imagine that the result would be very similar to that obtained by the Vatican – far fewer laws, especially marginal ones, are likely to get through. And after a little public humiliation, there’s a good chance that the laws that are proposed would be shorter, better crafted. Attempts at earmarking and political chicanery would broadcast far and wide for the world to see. Hallelujah and Amen!

So this is a great idea, but it’s clearly unlikely to happen. After all, if Pope John Paul II eliminated the position of Devil’s Advocate after it had been in use for nearly 400 years just so he could go on a sainting spree, what chance does Congress have of weaning itself off of lobbyists, earmarks and legislation based upon good policy rather than good politics? That leaves us with one final alternative: science.

Earlier this year, Ben Goldacre’s “Bad Science” blog had an interesting post entitled “We Should So Blatantly Do More Randomised Trials On Policy”. In it, he pointed out that the world of randomized controlled trials (RCTs)was not necessarily limited to science and medicine, but had proven real-world applications in many areas of social, economic and public policy:

“Randomised trials are our best way to find out if something works: by randomly assigning participants to one intervention or another, and measuring the outcome we’re interested in, we exclude all alternative explanations for any difference between the two groups. If you don’t know which of two reasonable interventions is best, and you want to find out, a trial will tell you.

Microfinance schemes help small producers buy in bulk to make larger profits, and they change lives. But are group-liability loans better, because people default less, so the project is more sustainable? Or do anxieties about shared responsibility restrict recruitment? Some academics ran a trial.

Do free uniforms improve school attendance, especially in pupils who don’t own one at all? Someone ran a trial. Contingent payments improve attendance: but what’s the best time to pay, and how? There’s another trial. What about streaming in Kenyan schools, with high and low ability classes? Do all kids do better? Someone ran a trial. Maybe different strategies to encourage saving work best in different places? Innovations for Policy Action ran a series of trials to find out, in the Philippines, in Bolivia, in Peru.

I won’t tell you the results, for any of those projects: because this isn’t about good news on what works, or bad news about what doesn’t. What matters is that someone ran a randomised trial and found the answer…

…So here is my fantasy. We sack the Behavioural Insights Team – all they’ll do is overextrapolate from behavioural economics research – and open a Number Ten Policy Trials Unit instead.

They sit down to write a giant list of unanswered questions, for situations where we don’t know if an intervention works: this will be most of them. Then we filter down to questions where a randomised trial can feasibly be run. Then we do them.

This won’t cost money: it will save money, in unprecedented amounts, by permitting disinvestment in failed interventions, and it will transform the country. It’s efficient, it’s sensible, and it will never happen, because politicians are too ignorant of these simple ideas, too arrogant to have their ideologies questioned, and too scared – let’s be generous – of hard data on their good intentions.”

Readers of this blog already know that the Road to Hellth is paved with plenty of good intentions, so Goldacre’s fantasy for Britian is just as intriguing here in the USA. Imagine if, instead of implementing the current Resource-Based Relative Value System (RBRVS) across the land by legislative fiat back in 1992, Congress had instead mandated the creation of one or more RCTs focused on the optimal means of paying clinicians for seeing Medicare patients. One arm would have retained the payment method in existence at the time. A second would have implemented the highly complex RBRVS that currently afflicts American healthcare. A third might have included some trial of HMOs, as “Accountable Care Organizations” were known at the time. Finally, a fourth arm would have implemented a simple program of paying doctors for their time on an hourly basis as we’ve described previously. The endpoints evaluated by this study would have included measures of the total burden of costs imposed on the healthcare system, ease of implementation, patient and clinician satisfaction, access to care and relevant data regarding the quality of care provided for certain important diseases. Under these conditions, we believe that there is no way that the RBRVS system would have proven itself suitable for widespread use, nor would HMOs/ACOs have been shown to be economically and clinically viable. Billions, and even trillions of dollars might have been saved on behalf of Medicare, physicians, businesses patients and taxpayers.

But here again one has to ask: “Is there any reason to believe that legislators in general, and the U.S. Congress in particular, are willing to exchange real science, real data and the real world for the wooing of lobbyists, the lure of political expediency and the siren song of good intentions?” Hardly. Ours is a political world in which Mitt Romney contends that the healthcare program he initiated in Massachusetts and the ACA bear no resemblance to one another, and President Obama seriously claims that his healthcare reform legislation will cost less than $1 trillion. Where’s the evidence that the real world and real facts matter to these people?

Which brings us to the heart of the matter. Can rational people ever be comfortable with government control of healthcare through a “single payer” system, knowing that the legislative system of representation is characterized by – and we mean this in the kindest possible way – ignorance, manipulation, short-term thinking, political tribalism and the urge to act in the absence of the facts? Especially when we know that the laws passed will then be administered by unaccountable bureaucracies? It’s a risky business, made riskier by the unlimited authority of government punish those with whom it disagrees. And although there are tools that can be used to mitigate the risk, it would be wise to implement these and gauge their effectiveness in a less important realm before putting the government in complete control of nearly one-fifth of the economy.

Given our recent track record of good governance, anything else is just playing with dynamite.

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*The problem is made still worse by deliberate measures taken to ensure that legislators don’t even know what they’re voting on. In the case of the ACA these included voting on an absurdly large 2,400 page bill before anyone had time to read it, prompting Speaker Nancy Pelosi’s famous remark that it had to be passed “so you can find out what’s in it”.